Clinical effectiveness of adjunctive antimicrobial photodynamic therapy for residual pockets during supportive periodontal therapy: A systematic review and meta-analysis

Multiple Sessions of Antimicrobial Photodynamic Therapy Improve Periodontal Outcomes in Patients with Down Syndrome: A 12-Month Randomized Clinical Trial

Background/Objectives: Individuals with Down syndrome (DS) often present with severe periodontal disease at a young age. Adjuvant treatments to scaling and root planing (SRP), such as antimicrobial photodynamic therapy (aPDT), may benefit this population. This study evaluated the effectiveness of aPDT as an adjunct to SRP in individuals with DS. A randomized, double-blind, parallel trial was conducted with 37 individuals with DS. Methods: The test group (aPDT; n = 18) received SRP + aPDT, while the control group (C group; n = 19) received SRP only. For aPDT, a red laser (658 nm; 0.1 W; 2229 J/cm2; 40 s sweeping with optical fiber) combined with methylene blue (MB) (100 µg/mL) was applied across repeated sessions (on days 3, 7, and 14). Clinical parameters, such as plaque index (PI), clinical attachment level (CAL), probing depth (PD), and bleeding on probing (BOP), were recorded at baseline and after 3, 6, and 12 months of treatment. Statistical analyses were performed using parametric and non-parametric tests (p < 0.05). Results: Both treatments promoted improvements in all clinical periodontal parameters (p < 0.05). The aPDT group showed a statistically significant reduction in CAL at 3 months (aPDT = 4.58 mm vs. C = 4.72 mm; p < 0.05) and 12 months (aPDT = 4.59 mm vs. C = 4.84 mm; p < 0.05). Conclusions: aPDT improved periodontal health in the long term through a stable gain in attachment.

Gingival crevicular fluid level of tumor necrosis factor-alpha as a valuable biomarker for estimation of the efficacy of adjunctive antimicrobial photodynamic therapy in stage II-IV periodontitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to assess the gingival crevicular fluid (GCF) level of tumor necrosis factor-alpha (TNF-alpha) as a valuable inflammatory cytokine for estimation of the efficacy of adjunctive antimicrobial photodynamic therapy (aPDT) in stage II-IV periodontitis patients.

METHODS

This review was conducted in accordance with the PRISMA statements, and registered in PROSPERO (CRD42022321211). An electronic search was conducted for articles comparing the efficacy of aPDT versus scaling and root planing (SRP) published up until June 2023. The mean GCF level of TNF-alpha and clinical attachment loss (CAL) with 95% confidence interval (CI) were pooled and compared between the groups using a random-effect model after 1-2, 4-5, 12-13, and ≥ 24 weeks. The I2 test was applied to assess the heterogeneity of the findings, and publication bias was evaluated by visual inspection of the funnel plot symmetry.

RESULTS

Analysis of 11 studies indicated a significant difference in GCF level of TNF-alpha at the 1-2, 12-13 and ≥ 24-week follow-ups in patients treated with aPDT + SRP. However, at the 4-5-week follow-up, the results were significant in favor of the control group (mean difference = -0.17, 95% CI = -1.86-152, P < 0.00001).

CONCLUSION

Despite the limitations of the included studies, aPDT can decrease the GCF level of TNF-alpha inflammatory biomarker for a longer period of time than SRP alone in grade II-IV periodontitis. However, further investigations are required to assess the efficacy of higher frequency of aPDT applications.

Indocyanine green based antimicrobial photodynamic therapy as an adjunct to non-surgical periodontal treatment in periodontal maintenance patients: a clinico-microbiological study

Background: Antimicrobial Photodynamic therapy for the treatment of periodontitis is being increasingly gaining attention but at present, very limited data are available on the clinical and microbiological outcomes obtained following Indocyanine Green as the photosensitizer in Maintenance patients. The objective was to evaluate the efficiency of Indocyanine(ICG)-green based photodynamic therapy as an adjunct to scaling and root planing in patients enrolled in maintenance therapy. Methodology: Using a split mouth study design, 24 participants enrolled in the maintenance therapy, having diagnosed as Periodontitis, were randomly subjected to scaling and root planing(SRP). The test group additionally received ICG-based (Aurogreen ®, Aurolabs, Madurai, India,1mg/ml) aPDT with an 810nm diode laser. Clinical assessment of Plaque index, modified Sulcus bleeding index, Probing pocket depth, Clinical loss of attachment and microbiological analysis of A. actinomycetemcomitans, P. gingivalis, T. forsythia and F.nucleatum were performed at baseline and 3 months after treatment. Results: It was observed that although there was no significant difference between the test and control group at baseline and 3 months, there was a statistically significant reduction in the mean values in both the groups at 3 months. Microbiological analysis showed substantial reduction in detection frequency of the bacteria assessed at 3 months in both the groups. Conclusion: Within the limits of the study, ICG-based aPDT did not show additional advantage over SRP alone at 3 months, though it could be a promising treatment modality in maintenance patients in terms of patient comfort and the treatment time taken. More randomised clinical trials should be employed to understand the exact mode of action of ICG based aPDT and its role in treatment of periodontal disease.

Association of active oxygen-releasing gel and photodynamic therapy in the treatment of residual periodontal pockets in type 2 diabetic patients: A randomized controlled clinical study

BACKGROUND

The aim of this study was to evaluate the effect of active oxygen-releasing gel as an adjuvant, with and without antimicrobial photodynamic therapy (aPDT), in the treatment of residual pockets in periodontal patients with type 2 diabetes mellitus (DM2).

METHODS

Patients with residual pockets with probing depth (PD) ≥4 mm and bleeding on probing (BOP) were divided into the following groups: SI (n = 17)-subgingival instrumentation in a single session; BM (n = 17)-SI followed by local application of active oxygen-releasing gel inside the periodontal pocket for 3 min; BM + aPDT (n = 17)-SI followed by application of BM for 3 min and pocket irrigation with methylene blue, and 660-nm diode laser irradiation at 100 mW for 50 s. The periodontal clinical parameters, serum levels of glycated hemoglobin, and immunological analysis of crevicular fluid were evaluated. All data were submitted to statistical analysis (α = 5%).

RESULTS

A significant reduction in BOP was verified at 90 and 180 days in the BM + aPDT group. The percentage of sites with PD ≥ 4 mm was significantly reduced at 90 days in BM + aPDT and BM, whereas after 180 days only BM showed a significant reduction. In the BM + aPDT group, there was a significant reduction in tumor necrosis factor α levels at 90 days. There were no differences between the treatments.

CONCLUSION

The use of adjuvant active oxygen-releasing gel, with or without aPDT, resulted in the same clinical benefits as SI in the treatment of residual pockets in poorly controlled DM2 patients.

Antimicrobial photodynamic therapy against oral biofilm: influencing factors, mechanisms, and combined actions with other strategies

Oral biofilms are a prominent cause of a wide variety of oral infectious diseases which are still considered as growing public health problems worldwide. Oral biofilms harbor specific virulence factors that would aggravate the infectious process and present resistance to some traditional therapies. Antimicrobial photodynamic therapy (aPDT) has been proposed as a potential approach to eliminate oral biofilms via in situ-generated reactive oxygen species. Although numerous types of research have investigated the effectiveness of aPDT, few review articles have listed the antimicrobial mechanisms of aPDT on oral biofilms and new methods to improve the efficiency of aPDT. The review aims to summarize the virulence factors of oral biofilms, the progress of aPDT in various oral biofilm elimination, the mechanism mediated by aPDT, and combinatorial approaches of aPDT with other traditional agents.

Engineering of bioactive nanocomplexes on dental floss for targeted gingival therapy

Periodontitis induced by chronic subgingival infection is a ubiquitous disease that causes systemic inflammatory consequences and poses a negative impact on quality of life. The disease is treated and potentially prevented by patient's self-care aimed at eliminating the oral pathogens from the region. Currently available products for interdental self-care, including dental floss and interdental brush, have limited ability to prevent the disease. Here, we report a coated dental floss thread, termed "nanofloss," which uses polyphenol-based nanocoating to functionalize the floss thread with therapeutic agents. Multiple therapeutics can be integrated into the nanofloss including antibacterial small molecules and proteins. Flossing with nanofloss-delivered therapeutic agents to the challenging subgingival region with long-term retention even against the flushing action of the oral fluid in vivo. Our in vitro and in vivo studies demonstrate that chlorhexidine gluconate-loaded nanofloss effectively treats the subgingival infection by Porphyromonas gingivalis. Collectively, the nanofloss offers a promising and easily usable tool for targeted self-care of subgingival infection against periodontitis.

Photodynamic Therapy by Mean of 5-Aminolevulinic Acid for the Management of Periodontitis and Peri-Implantitis: A Retrospective Analysis of 20 Patients

Periodontitis and peri-implantitis are common in the population worldwide. Periodontal diseases affect approximately 50% of adults, while mucositis affects 80% of patients with implants, turning into peri-implantitis at a rate varying from 28 to 58%. If standardized treatments for all degrees and variety of periodontal diseases are known and codified, a consensus on the treatment of peri-implantitis still has to be found. Photodynamic therapy (PDT) has been used successfully in the medical field and was recently introduced as supportive therapy in dentistry. This paper reviews the results on 20 patients, 10 affected by periodontal disease (grades II to III) and 10 by peri-implantitis. Application of 5% 5-aminolevulinic acid gel (ALAD), as a support of causal therapy, in periodontal pockets and areas of peri-implantitis favored the maintenance of severely compromised teeth and significantly improved compromised implant conditions. Between baseline and 6 months, all teeth and implants remained functional. All patients confirmed that the scaling and root planning (SRP)+ALAD-PDT was not painful, and all perceived a benefit after the treatment at all timing points. For periodontal patients, a significant decrease in PPD after 3 (p < 0.001) and 6 months after SRP+ALAD-PDT respect baseline values were observed. For the implant patients, the SRP+ALAD-PDT was correlated to a decrease in PPD and BOP, and a slight increase in the number of exposed threads. However, the results were statistically significant only for PPD (p < 0.001).

The efficacy of adjunctive periodontal therapies during supportive periodontal care in patients with residual pockets. A systematic review and meta-analysis

While it is well-established that patients that develop signs of relapsing periodontitis in supportive periodontal care (SPC) will need to repeat subgingival instrumentation of the residual pockets, less certainty is available in terms of which protocol should be followed and whether the use of adjunctive therapies or physical agents might provide additional benefits to repeated instrumentation alone. The aim of this systematic review was therefore to assess whether repeating subgingival instrumentation in combination with adjunctive therapies (other than antimicrobials) might provide a significant benefit in terms of pocket closure, probing pocket depth (PPD) reduction or clinical attachment level (CAL) gain in patients during SPC with residual/relapsing pockets. Four databases were searched to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) with a minimum follow-up of 3 months that investigated the use of adjunctive therapies (other than antimicrobials) in case of residual/relapsing pockets in patients in SPC since at least 3 months. Data extraction and risk of bias assessment were performed in the studies meeting the inclusion criteria and meta-analysis was performed when ≥3 studies assessing the same adjunctive therapy were identified. 12 studies (2 CCTs and 10 RCTs) were included for qualitative analysis. Meta-analysis was performed only for 3 studies on the adjunctive use of photodynamic therapy (PDT) and it indicated a nonsignificant benefit compared to the placebo in terms of PPD reduction and CAL gain at 3 months (weighted mean difference 0.07 and -0.03, respectively) and at 6 months of follow-up (weighted mean difference -0.09 and -0.18, respectively). While antiseptics did not provide significant benefits, one study on probiotics and one on the use of vitamin D and calcium supplementation showed significant improvements in periodontal parameters. There is currently insufficient/poor evidence to determine the efficacy of adjunctive strategies (other than antimicrobials) to improve the outcomes of SPC in case of residual/relapsing pockets.

How can biophotonics help dentistry to avoid or minimize cross infection by SARS-CoV-2?

Biophotonics is defined as the combination of biology and photonics (the physical science of the light). It is a general term for all techniques that deal with the interaction between biological tissues/cells and photons (light). Biophotonics offers a great variety of techniques that can facilitate the early detection of diseases and promote innovative theragnostic approaches. As the COVID-19 infection can be transmitted due to the face-to-face communication, droplets and aerosol inhalation and the exposure to saliva, blood, and other body fluids, as well as the handling of sharp instruments, dental practices are at increased risk of infection. In this paper, a literature review was performed to explore the application of Biophotonics approaches in Dentistry focusing on the COVID-19 pandemic and how they can contribute to avoid or minimize the risks of infection in a dental setting. For this, search-related papers were retrieved from PubMED, Scielo, Google Schoolar, and American Dental Association and Centers for Disease Control and Prevention databases. The body of evidence currently available showed that Biophotonics approaches can reduce microorganism load, decontaminate surfaces, air, tissues, and minimize the generation of aerosol and virus spreading by minimally invasive, time-saving, and alternative techniques in general. However, each clinical situation must be individually evaluated regarding the benefits and drawbacks of these approaches, but always pursuing less-invasive and less aerosol-generating procedures, especially during the COVID-19 pandemic.

LASER in periodontal treatment: is it an effective treatment or science fiction?

There are several studies that evaluate the use of lasers in periodontal treatment in non-surgical or surgical therapy. However, while several studies showed clinically beneficial effects of some lasers in periodontal treatment, there are few clinical reports of additional advantages of lasers as adjunctive treatments in periodontology. The aim of this paper is to demonstrate and critically analyze the level of scientific evidence of effects of low-level lasers and high-power lasers in periodontology. A narrative review of the studies was carried out in each topic and type of laser or periodontal treatment. In nonsurgical periodontal therapy the results showed that there is an additional clinical benefit when using a diode laser (DL) associated with scaling and root planing (SRP) in patients with moderate to severe periodontitis. The Er:YAG laser seems to be the most suitable for nonsurgical periodontal therapy and promotes the same clinical effects as conventional therapy. In periodontal surgery vaporization of the gingival or mucosal tissue can be carried out with DL, CO2, Nd:YAG, Er:YAG and Er,Cr:YSGG lasers. Photobiomodulation (PBM), mediated by low-level lasers associated with non-surgical periodontal therapy, promotes additional benefits in the short term and accelerates the bone and gingival tissue repair process and also reduces postoperative symptoms of periodontal surgery. The effect of antimicrobial Photodynamic Therapy is relevant in the initial reevaluation periods. Studies have shown controversial results of the use of lasers in periodontics, and this fact may be due to the lack of standard parameters of irradiation in each clinical application.

Clinical efficacy of single and multiple applications of antimicrobial photodynamic therapy in periodontal maintenance: A systematic review and network meta-analysis

BACKGROUND

At present the clinical efficacy of single (S) versus multiple (M) applications of antimicrobial photodynamic therapy (aPDT) is controversially discussed.

AIM

To systematically evaluate the clinical efficacy of adjunctive S and M applications of aPDT to subgingival debridement (SD) in the treatment of residual periodontal pockets.

METHODS

An electronic search was carried out for randomized controlled clinical trials (RCTs) reporting on SD with the adjunctive use of S- or M-aPDT applications.

RESULTS

Statistically significantly higher improvement in bleeding on probing (BOP) and probing depth (PD) reduction was found for SD + S-aPDT versus SD, with Mean difference (MD) = -16.8 (95% CI: -30.7 to -2.91; p = 0.02) and 0.4, (95% CI: 0.02 to 0.78, p = 0.04), respectively. Regarding BOP, there was also a statistically significant difference when SD + M-aPDT was compared with SD alone, with a MD of -5.13 (95% CI: -7.20 to -3.07; p < 0.00001). For all parameters, SD + S-aPDT demonstrated the best treatment ranking of probability results, followed by SD + M-aPDT and SD alone.

CONCLUSIONS

Within their limits, the present data indicate that in periodontal patients enrolled in maintenance: a) single and multiple adjunctive applications of aPDT following SD resulted in statistically significant BOP reduction compared to SD alone, and b) repeated applications of aPDT did not seem to result in superior outcomes compared to single applications.

[Progress on photodynamic therapy in oral diseases]

Photodynamic therapy (PDT) has developed rapidly in basic and clinical research, and its therapeutic prospects have received increasing attention. PDT has the advantages of minimally invasive, low toxicity, high selectivity, good reproducibility, protection of appearance and vital organ function, and has become a treatment. With the development of medicine, the field of application of PDT becomes more wildly, and brings a new direction for the treatment of oral diseases. This article reviews the basic principles, treatment elements and research results of PDT in the treatment of oral diseases.

Efficacy of alternative or additional methods to professional mechanical plaque removal during supportive periodontal therapy: A systematic review and meta-analysis

AIMS

To systematically review the literature addressing the following focused questions: "What is the efficacy of either (#1) alternative or (#2) additional methods to professional mechanical plaque removal (PMPR) on progression of attachment loss during supportive periodontal therapy (SPT) in periodontitis patients?".

METHODS

A systematic search for randomized clinical trials was performed. Change in clinical attachment level (CAL) from baseline was the primary outcome.

RESULTS

Routine PMPR performed with either a combination of ultrasonic/hand instruments or Er:Yag laser showed similarly effective in preventing CAL loss. Moreover, a routine SPT regimen based on PMPR led to stability of CAL irrespective of a daily sub-antimicrobial doxycycline dose (SDD). Finally, an adjunctive photodynamic therapy (PDT) did not enhance the magnitude of CAL gain when sites with probing depth ≥4 mm were repeatedly treated. After pooling all data, the results of the meta-analysis showed no statistical differences in CAL change from baseline: mean overall CAL change was -0.233 mm (95% confidence interval: -1.065, 0.598; p = .351).

CONCLUSIONS

Weak evidence indicate that in treated periodontitis patients enrolled in a 3-4 month SPT based on PMPR, Er:Yag laser (as alternative), SDD and PDT (as additional) do not produce a greater clinical effect on periodontal conditions compared to PMPR.

Adjunctive local treatments for patients with residual pockets during supportive periodontal care: A systematic review and network meta-analysis

AIM

This systematic review and network meta-analysis aimed to evaluate the efficacy of adjunctive locally delivered antimicrobials, compared to subgingival instrumentation alone or plus a placebo, on changes in probing pocket depth (PPD) and clinical attachment level (CAL), in patients with residual pockets during supportive periodontal care.

MATERIALS AND METHODS

Literature search was performed with electronic databases and by hand until 31 May 2020. Primary outcome was the changes in PPD. The treatment effects between groups were estimated with weighted mean differences (WMD) with 95% confidence intervals (CI) and prediction intervals (PI) by using random-effects network meta-analysis.

RESULTS

Twenty-two studies were included. Significantly greater PPD reduction was achieved in chlorhexidine chip group (WMD: 0.65 mm, 95% CI: 0.21-1.10) and tetracycline fibre group (WMD: 0.64 mm, 95% CI: 0.20-1.08) over 6-month follow-up. Other adjunctive antimicrobial agents achieved non-significant improvements compared to scaling and root planing alone. All differences between adjunctive therapies were statistically non-significant. Similar findings were observed for CAL gain.

CONCLUSION

Adjunctive local antimicrobial agents achieved small additional PPD reduction and CAL gain in residual pockets for a follow-up of up to 6 months. Tetracycline fibre and chlorhexidine chip achieved better results than other antimicrobials.

A review of antimicrobial photodynamic therapy (aPDT) in periodontitis

Introduction:Periodontitis is an inflammatory disease caused by a multitude of pathogens, that eventually affects the entirety of all periodontal tissues and may lead to tooth mobility or even tooth loss. The destruction of said tissues occurs via 2 pathways: a direct pathway (defense mechanisms belonging to the pathogens) and an indirect pathway (the host’s immune system). Therapy is complex and requires strict follow-ups in order to prevent relapse. Aim: Our objective was to determine whether or not aPDT can be considered to be an effective adjunctive approach to the current standard initial treatment method when dealing with periodontitis (scaling/root planing). Methods: We performed an electronical search of the PubMed and ScienceDirect data bases starting from January 2014 and up to May 2019. Eligibility criteria included English-language systematic reviews and randomized clinical trials which evaluated the efficiency of aPDT, and that had been carried out on human subjects with permanent dentition. We excluded studies and reviews that were focused on the microbiology and/or immunology in photodynamic therapy and also those that used other LASER treatment modalities than aPDT. Results: Current literature displays many opinions regarding periodontal therapy with adjunctive aPDT, but it seems to be mainly regarded as a safe, effective and easy-to-use approach. Conclusion: aPDT seems to be efficient in the treatment of periodontitis when carried out additionally to classical scaling/root planing. Residual pockets seem to respond well to aPDT, as opposed to subsequent debridement flap elevation and its consequences on hard and soft tissues. However, further studies with a stricter treatment protocol and subsequent follow-ups are required in order to obtain a firmer conclusion. Key words: periodontitis LASER, periodontitis aPDT, periodontitis photodynamic therapy,

Advancing antimicrobial strategies for managing oral biofilm infections

Effective control of oral biofilm infectious diseases represents a major global challenge. Microorganisms in biofilms exhibit increased drug tolerance compared with planktonic cells. The present review covers innovative antimicrobial strategies for controlling oral biofilm-related infections published predominantly over the past 5 years. Antimicrobial dental materials based on antimicrobial agent release, contact-killing and multi-functional strategies have been designed and synthesized for the prevention of initial bacterial attachment and subsequent biofilm formation on the tooth and material surface. Among the therapeutic approaches for managing biofilms in clinical practice, antimicrobial photodynamic therapy has emerged as an alternative to antimicrobial regimes and mechanical removal of biofilms, and cold atmospheric plasma shows significant advantages over conventional antimicrobial approaches. Nevertheless, more preclinical studies and appropriately designed and well-structured multi-center clinical trials are critically needed to obtain reliable comparative data. The acquired information will be helpful in identifying the most effective antibacterial solutions and the most optimal circumstances to utilize these strategies.